NAME OF PROGRAM: / / MALE CHILD’S LAST NAME CHILD’S …
[Pages:2]HEALTH RECORD FOR CHILDREN IN DAY CAMP, AFTERSCHOOL & YOUTH CENTERS
(This side is to be completed by Parent before presenting to Physician)
NAME OF PROGRAM: ______________________________________________________________________
______________________________ _________________________________ ______/______/_____ FEMALE MALE
CHILD'S LAST NAME
CHILD'S FIRST NAME
DATE OF BIRTH
__________________________________________________ ________________________
HOME ADDRESS
CITY/STATE/ZIP CODE
____________________________________________________________________________
PARENT'S OR GUARDIAN'S NAME
______________________________
HOME TELEPHONE NUMBER
______________________________
CONTACT TELEPHONE
____________________________________________________________________________
FATHER'S PLACE OF EMPLOYMENT
______________________________
TELEPHONE
____________________________________________________________________________
MOTHER'S PLACE OF EMPLOYMENT
______________________________
TELEPHONE
____________________________________________________________________________
IN CASE OF EMERGENCY-NOTIFY
______________________________
TELEPHONE
IF PARENT OR GUARDIAN IS NOT AVAILABLE IN AN EMERGENCY, NOTIFY: (FAMILY PHYSICIAN)
1.__________________________________________________________________________
______________________________
OR 2.__________________________________________________________________________
TELEPHONE
______________________________
TELEPHONE
IMPORTANT: Please notify Camp Officials if Child was/is exposed to any communicable disease at anytime three weeks prior to Camp attendance.
NO YES If YES, please give type of exposure:
______________________________________________________________________________
HEALTH HISTORY (Check, giving approximate dates):
Asthma:__________________________
Behavior:_______________________
Chicken Pox:_____________________
Convulsion:_______________________
Diabetic:________________________ Ear Infection:____________________
Hay Fever: _______________________ Insect Stings: ___________________ Ivy Poisoning, etc: _______________
Measles: ________________________ German Measles: ________________ Mumps: ________________________
Past Illness: _______________________________________________
Contagious illness: __________________________
Other Drugs: ______________________
Penicillin: ______________________ Rheumatic Fever: ________________
Operations or Serious Injuries (Dates): ____________________________________________________________________
Hospitalization: ______________________________________________________________________________________
Chronic or Recurring Illness: ____________________________________________________________________________
Other Diseases or details of above: ______________________________________________________________________
Any specific activities to be encouraged? __________________________________________________________________
Any specific activities to be restricted? ____________________________________________________________________
Permission for all program activities unless otherwise noted by physician:
______________________________________________________________________________________________________
Suggestion from Parent(s) or Guardian:_______________________________________________________________________
SIGNIFICANT HEALTH HISTORY AND CURRENT CONDITIONS PLEASE LIST: Medication taken: _____________________________________________________________________________________________________________________ Appliance worn (Glasses, Hearing Aid, etc.): _________________________________________________________________________________________ Conditions that modify activity (seizures, asthma, heart condition, etc.): _____________________________________________________________
CONSENT FOR EMERGENCY MEDICAL TREATMENT
I hereby give my consent/authority to the Staff of the Day Camp, year round Afterschool, and Youth Center Program to obtain the necessary emergency medical treatment for my child with the understanding that the family will be notified as soon as possible. Relationship: ____________________________ Signature: _____________________________________ Telephone: _________________________ Date: _____________
(To be filled out by Physician ? Please note information on reverse side) The purpose of this health record is to provide the staff with pertinent information, which will help to serve the need of the aforementioned Child in Day Camp and Afterschool and Youth Center programs.
IMMUNIZATION HISTORY (This is a record of dates of basic immunization and most recent booster doses)
DPT or DT or TD ? POLIO -
MEASLESMUMPS-
RUBELLA-
DATE:__________ DATE:__________ DATE: __________ DATE:__________ DATE:___________ DATE:__________ DATE:__________ DATE:__________ DATE:__________ DATE:___________ DATE:__________ DATE:__________ DATE:__________
(PPD-MANTOUX) Tuberculin Test given: ___________________ (most recent)
Result:__________
m m
MEDICAL EXAMNATION (To be completed by licensed Physician)
EXAMINATION IS ACCEPTABLE WHEN PERFORMED NO MORE THAN 12 MONTHS PRIOR TO ARRIVAL AT CAMP.
CODE: S = SATISFACTORY
X = NOT SATISFACTORY (EXPLAIN) O = NOT EXAMINED
________________________________________________________________________________________________________________
GENERAL APPERANCE
________________________________ HEIGHT
_____________________________ WEIGHT
___________________________ BLOOD PRESSURE
______________________________ HGB. TEST
________________________________ URINALYSIS
_____________________________ POSTURE & SPINE
________________________________________________________ THROAT/TONSILS
________________________________ EYES
_____________________________ VISION
__________________________ GLASSES
______________________________ EXTREMETIES
________________________________ HEART
_____________________________ EARS
__________________________ HEARING
______________________________ FEET
________________________________ LUNGS
_____________________________ SKIN
__________________________ NOSE
______________________________ TEETH
________________________________ ABDOMEN
____________________________ HERNIA
______________________________________________ __________ GENITALIA
ALLERGY (PLEASE SPECIFY):____________________________________________________________________________________________________ _____________
EUROLOGICAL FINDINGS:____________________________________________________________________________________________________________________
DESCRIBE ABNORMAL FINDINGS AND/OR HANDICAPPING CONDITIONS:____________________________________________________________________________ ___________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________ _______________
HAS CHILD EVER RECEIVED PRODUCTS CONTAINING HORSE SERUM?
NO YES If YES, Please explain.
________________________________________________________________________________________________________ SPECIAL DIET
________________________________________________________________________________________________________ MEDICAL MEDICATION (GIVE NAME AND DOSAGE)
________________________________________________________________________________________________________ PARENT/GUARDIAN SEEKING SPECIAL MEDIATION?
____________________________________ SWIMMING
______________________________ DIVING
____________________________ STRENUOUS ACTIVITY
GENERAL APPRAISAL: ________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
I HAVE EXAMINED THE INDIVIDUAL HEREIN DESCRIBED, REVIEWED HIS/HER HEALTH HISTORY AND IT IS MY OPINION THAT HE/SHE IS PHYSICALLY ABLE TO ENGAGE IN CAMP/YEAR ROUND AFTERSCHOOL AND YOUTH CENTER ACTIVITIES, EXCEPT AS NOTED ABOVE.
_________________________________________________________________________M.D. PHYSICIAN'S SIGNATURE
________________________________________________ DATE
_________________________________________________________ ADDRESS
_______________________________________ CITY/STATE
______________________ ZIP CODE
................
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